Nursing 211 – Introduction to Therapeutic Nursing Interventions

 

Mental Status Assessment

 

 

 

 

 

GUIDELINES FOR MENTAL STATUS ASSESSMENT

 

1.      Describe the setting and circumstances in which you completed the Mental Status Assessment.  How did you prepare yourself and your client for this assessment?

 

    1. Describe the client’s mental status in terms of the six parameters on page one of the assessment form.  Write a brief paragraph for each area.  Then describe the results of the Folstein Mini-Mental Exam.  How did the client answer each question, and how did you score it?  What was the total score?  What doe this score mean?  In reviewing all of your data, what is your assessment of your client’s mental status (client’s strengths and weaknesses)?  Did anything interfere with the accuracy of your assessment?

 

    1. Reflections:  How did you feel doing this assessment?  How did your client react to the assessment?

 

Self-evaluation:  What did you do well?  What would you do differently next time?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. General Appearance and Motor Behavior

 

 

 

 

 

 

2. Speech

 

 

 

 

 

 

3. Mood and Affect

 

 

 

 

 

 

4. Thought Processes

 

 

 

 

 

 

5. Sensorium and Intellectual Functioning

 

 

 

 

 

 

6. Judgment and Insight

 

 

 

 

Instructions: Ask all questions in order listed and score immediately.  Record total number of points.

                        Maximum       

                        Score               Score                                       Question

Orientation              5                      (  )              1. Ask the patient to name the year, season,

                                                                            Date, day, and month. (1 point each)

                              5                      (  )              2. Ask the patient to give his/her

                                                                            whereabouts: state, county, town , street,

                                                                             floor.  (1 point each)

Registration             3                      (  )              3. Ask the patient to repeat three unrelated

                                                                            objects that you name.  Repeat them and

                                                                            continue to repeat them until all three are

                                                                            learned.  (1 point each)         

Attention and

Calculation              5                      (  )              4. Ask the patient to subtract 7 from 100,

                                                                            stopping  after five subtractions or to spell

                                                                            the word “world” backwards.  (1 point for

                                                                            each correct calculation or letter)

Recall                     3                      (  )              5. Ask the patient to repeat the three objects

                                                                            previously named. (1 point each)

Language                2                      (  )              6. Display a wristwatch and ask the patient

                                                                            to name it.  Repeat this for a pencil.

                                                                             (1 point each)

                              1                      (  )              7. Ask the patient to repeat this phrase: “No

                                                                            ifs, ands, or buts!” (1 point)

                              3                      (  )              8. Have the patient follow a three-point

                                                                             command, such as “Take a paper in your

                                                                             right hand, fold it in half, and put it on

                                                                            the floor.” (1 point each)

                              1                      (  )              9. On a blank piece of paper write “Close

                                                                             your eyes!”  Ask the patient to read it

                                                                             and do what it says.  (1 point)

                              1                      (  )              10. Ask the patient to write a sentence on a

                                                                              blank piece of paper.  It must be written

                                                                              spontaneously.  Score correctly if it

                                                                              contains a subject, a verb, and is sensible

                                                                              (correct grammar and punctuation are

                                                                              not necessary).  (1 point)

                              1                      (  )              11. Ask the patient to copy a design you

                                                                               have drawn on a piece of paper (two

                                                                               intersecting pentagons with sides

                                                                               about 1 inch).  (1 point)

 

TOTAL SCORE:    ___________      (Maximum Score = 30)

 _______________________________________________________________________

SCORING: Score of 23 or less:     High likelihood of cognitive defect

                     Score of 25-30:         Normal aging or borderline                        

 

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